Social anxiety and posttraumatic stress symptoms: The impact of distressing social events

Journal of Anxiety Disorders 25 (2011) 49–57

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Journal of Anxiety Disorders

Social anxiety and posttraumatic stress symptoms: The impact of distressing social events夽 R. Nicholas Carleton ∗ , Daniel L. Peluso, Kelsey C. Collimore, Gordon J.G. Asmundson Anxiety and Illness Behaviours Laboratory and Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK, S4S 0A2, Canada

a r t i c l e

i n f o

Article history: Received 27 March 2010 Received in revised form 9 July 2010 Accepted 2 August 2010 Keywords: Social anxiety SAD Posttraumatic stress Vulnerability factors

a b s t r a c t Recent evidence supports the notion that relatively common social events, such as public humiliation and teasing, may precipitate or exacerbate symptoms of social anxiety disorder (SAD; Erwin et al., 2006; McCabe et al., 2010). In addition, individuals with SAD often report event-specific hallmark symptoms of posttraumatic stress (PTSS; e.g., intrusive memories, avoidance, hyperarousal) following significant negative social events. Although intriguing, there is a paucity of research data to date exploring the relationships between negative social events, social anxiety, and PTSS. The present study (1) assessed endorsement rates of negative social events; (2) compared patterns of social anxiety and PTSS reporting among persons reporting negative social events relative to persons reporting the Criterion A1 events associated with posttraumatic stress disorder; and (3) evaluated the interrelationships between social anxiety and PTSS, and common constructs including fear of negative evaluation, anxiety sensitivity, and depression. Participants included community members (n = 601; 74% women; Mage = 25.8, SD = 9.8) who endorsed experiencing a significantly negative social event. Approximately 55% of all participants reported experiencing a negative social event, with one-third of those indicating it was worse than the Criterion A events they had experienced. Participants reporting negative social events scored higher on measures of social anxiety and PTSS than those reporting only Criterion A events. Trauma symptoms only predicted social anxiety symptoms for participants who reported a negative social event. Comprehensive results and directions for future research are discussed. © 2010 Elsevier Ltd. All rights reserved.

1. Introduction Social anxiety disorder (SAD) typically involves persistent, disabling distress and/or avoidance associated with social interaction or performance situations (American Psychiatric Association, 2000). The disorder is often present since early childhood (Albano & Detweiler, 2001; Beidel, 1998), and can markedly interfere with the development and maintenance of interpersonal relationships (Henderson & Zimbardo, 2001). Diathesis-stress models suggest that environmental factors interact with pre-existing vulnerability factors (e.g., biological and psychological vulnerabilities), which lead to the development of emotional disorders (Barlow, 2002). Recent research suggests that a negative social stressor may be a particularly prevalent environmental factor implicated in the development of SAD symptoms (Erwin, Heimberg, Marx, & Franklin, 2006).

夽 K.C. Collimore is supported by a CIHR Doctoral Research Award (FRN: 85321). ∗ Corresponding author. Tel.: +1 306 347 2415; fax: +1 306 337 3275. E-mail addresses: [email protected], [email protected] (R.N. Carleton). 0887-6185/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2010.08.002

The notion of a single stressor resulting in ongoing and eventspecific or event-related pathology is not new, but is probably most often associated with posttraumatic stress disorder (PTSD; American Psychiatric Association, 2000). The question of what constitutes a traumatic stressor has been the subject of substantial debate (Beidel, 1991; McNally, 2003), and is further complicated by evidence that non-life threatening stressors can result in substantial distress. There is some evidence that people experiencing non-life threatening events (e.g., chronic illness, marital discord, or unemployment) report more event-specific posttraumatic stress symptoms (PTSS) than people experiencing imminently life threatening events (e.g., disaster or motor vehicle accident; Vanheule, Desmet, Groenvynck, Rosseel, & Fontaine, 2008). For example, victims of sexual harassment frequently meet symptom criteria for PTSD (Carleton, Gosselin, & Asmundson, 2010; Morley, Williams, & Black, 2002), and it could be argued that such harassment does not meet Criterion A1. Individuals have also reported event-specific symptoms of PTSD (e.g., intrusive memories, avoidance, hyperarousal; Ward, 2006) following a significantly negative social event, and these SAD symptoms can become pervasive and remain stable (Abramowitz, Taylor, & McKay, 2009). Indeed, socially anxious college students report more frequent intrusive thoughts and images

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of negative social events than nonanxious students (Chasson et al., 2010). A variety of negative social events (e.g., public humiliation, teasing, bullying) may be extremely upsetting and distressing and contribute to the development of SAD symptoms (Gatz, Johansson, Pedersen, Berg, & Reynolds, 1993; Ward, 2006). Indeed, longitudinal and cross-sectional studies comparably demonstrate that negative social events – particularly in childhood – can result in a variety of internalizing and externalizing problems (e.g., SAD, fears of negative evaluation, depressed mood, loneliness, body dissatisfaction, eating disturbances, somatic complaints, and poor self-esteem; Rigby, 2003; Roth, Coles, & Heimberg, 2002; Storch, Brassard, & Masia-Warner, 2003; Storch & Ledley, 2005; Storch et al., 2004). Despite the nature of these events, they rarely, if ever, meet the DSM-defined thresholds described by Criterion A1 (American Psychiatric Association, 2000). There appear to be only two direct investigations of negative social events resulting in PTSS. The first investigation included a sample of 30 people with self-reported specific phobias of speeches (Hofmann, Ehlers, & Roth, 1995). Participants reported panic attacks and traumatic social experiences as the two primary reasons for their fear of speeches; however, none of them reported developing the speaking phobia following an unpleasant speaking situation. In a subsequent investigation, a sample of 45 patients with SAD was assessed and more than one-third met criteria for a PTSS pattern in connection with a stressful social event (Ward, 2006). Furthermore, of the 29 patients who reported experiencing both a socially stressful event and a Criterion A1 event, 14% met PTSD Criteria B through F for their worst socially stressful events, but not for their worst Criterion A1 event. Despite the apparent associations between significantly negative social events and PTSS, distressing social events remain relatively understudied. The intention of the current study is not to evaluate whether social events perceived to be distressing should be accepted as meeting Criterion A1; instead, the intention is to evaluate the relationship between social anxiety symptoms and PTSS. The purpose of the present investigation was threefold. First, to further assess the endorsement rates of significantly negative social events perceived as distressing or traumatic and create three groups, (a) persons who have experienced a significantly negative social event and believe it was the worst event they have ever experienced; (b) persons who have experienced a significantly negative social event but believe some Criterion A1 event was the worst event they have ever experienced; and (c) persons who have only experienced Criterion A1 event(s) and believe one such event was the worst they have ever experienced. The second purpose was to compare PTSS and SAD symptom reporting across the three groups. Higher and more frequent SAD symptom reporting was expected among persons who have experienced a significantly negative social event. The third purpose was to evaluate the interrelationships between PTSS and SAD symptoms, and common constructs including fear of negative evaluation (Storch et al., 2003), anxiety sensitivity (Collimore, McCabe, Carleton, & Asmundson, 2008; Ressler et al., 2004; Storch et al., 2003), and depression (Otto et al., 2009; Turner, Beidel, & Frueh, 2005) within each of the three groups. The relationships between these constructs were assessed, controlling for depression symptoms as suggested and conducted by precedent research investigating social anxiety and PTSD (Frueh, Turner, Beidel, Mirabella, & Jones, 1996; McCabe, Miller, Laugesen, Antony, & Young, 2010). Symptoms of SAD were expected to be predicted by PTSS, fear of negative evaluation, and anxiety sensitivity in persons reporting a significantly negative social event as the worst event they have experienced; in contrast, only fear of negative evaluation and anxiety sensitivity were expected to predict symptoms of SAD in persons not reporting a significantly negative social event.

2. Methods 2.1. Participants Participants included community members (n = 601) from Canada [156 men, 18–54 years (Mage = 26.1; SD = 9.8) and 445 women, 18–55 years (Mage = 25.7 SD = 9.8)], who completed several self-report measures as part of larger investigations of general fears that were approved by the University of Regina Research Ethics Board. Participants were recruited via web-based advertising to participate in research exploring fear. Web-based data collection has been demonstrated to be a valid approach for questionnairebased research that is comparable to other data collection methods (Gosling, Vazire, Srivastava, & John, 2004) and is a method we have used successfully in several related investigations of fear constructs (e.g., Carleton & Asmundson, 2009; Carleton, Collimore, & Asmundson, 2007). Participants were not compensated. The majority of participants (71%) reported having at least some postsecondary education, being employed or working at home (21% full-time, 34% part-time, and 4% as homemakers), and being either part-time or full-time students (57%). Most participants identified their ethnicity as Caucasian (87%), Asian (4%), or First Nations (2%). Approximately two-thirds (64%) reported being single and another third (26%) reported being married. 2.2. Measures 2.2.1. Distressing or traumatic life events History of traumatic life events was assessed using an experimenter-designed scale assessing exposure to 16 different traumatic events (e.g., natural disaster, motor vehicle accident, sexual assault) commonly reported by community members, and based on the authors’ research and clinical experience. An openended ‘Other’ question was also included, where respondents could report any other traumatic events that they had experienced. If respondents indicated that they had been exposed to traumatic events, they were asked to indicate which event they believed to be the most distressing. Thereafter, the participant was asked approximately when that worst event first occurred, and in the case of multiple exposures, when the event most recently occurred (i.e., within the last month; 1–3 months ago; 4–6 months ago; 7 months to 1 year ago; 1–3 years ago; 4 or more years ago). In addition to traumatic events meeting DSM-defined Criterion A1 (e.g., being assaulted), three negative social events were included, (1) “being publicly humiliated (worse than others)”; (2) “being severely bullied (worse than others)”; and (3) “being ridiculed (very badly teased, worse than others)”. PTSD Checklist – Civilian version (PCL-C; Weathers, Litz, Huska, & Keane, 1994). The PCL-C is a 17-item self-report measure that corresponds to PTSS (i.e., reexperiencing, avoidance/numbing, and hyperarousal) as described in DSM-IV (American Psychiatric Association, 2000). Participants were instructed, “Thinking about the most distressing or traumatic event you identified above, please indicate how much each of the following problems has bothered you during the last month”. Accordingly, the participant response should reflect considerations of either a significantly negative social event or a Criterion A1 event. Items are rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely). Based on previous research, the avoidance and numbing symptoms were analyzed separately because of evidence for the distinct nature of the two constructs (Asmundson, Stapleton, & Taylor, 2004). The PCL-C has been found to have a high diagnostic efficiency of .90 (Buckley, Blanchard, & Hickling, 1996) and has demonstrated strong convergent validity with other trauma related measures (Weathers, Litz, Herman, Huska, & Keane, 1993). A cut-off score of 44 – with appropriate subscale endorsements (i.e., ensuring participants endorsed

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reexperiencing, avoidance, numbing, and hyperarousal symptoms) and reports of interference in work or leisure activities, romantic, family, or friend relationships – is typically associated with a probable diagnosis of PTSD, with specificity ranging from .83 to .99, and sensitivity ranging from .60 to .82 (Andrykowski, Cordova, Studts, & Miller, 1998; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Cordova et al., 1995; Forbes, Creamer, & Biddle, 2001; Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000; Weathers et al., 1993). For the current study, a cut-off score of 50 was used to further substantiate specificity. For the current sample, the internal consistency was acceptable for the reexperiencing (˛ = .91), avoidance (˛ = .78), numbing (˛ = .86), and hyperarousal (˛ = .91) subscales, as well as the total score (˛ = .95). The average inter-item correlation was .55. Social Interaction Phobia Scale (SIPS; Carleton et al., 2009). The SIPS is a 14-item self-report measure designed to assess symptoms specific to SAD. Each item is measured on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely). Respondents indicate how much each item bothered them during the past week. The items were derived as a subset of items from the Social Interaction Anxiety Scale and the Social Phobia Scale (Mattick & Clarke, 1998). The SIPS is designed to measure three symptom dimensions (i.e., social interaction anxiety, fear of overt evaluation, fear of attracting attention); however, use of the total score provides optimal sensitivity and specificity for discerning clinical and nonclinical samples (i.e., a cut-off score of 21 can typically be used to distinguish persons reporting clinically significant social distress; Carleton et al., 2009). For the current sample, the internal consistency was acceptable for the total score (˛ = .96) and the average inter-item correlation was .60. Anxiety Sensitivity Index-3 (ASI-3; Taylor et al., 2007). The ASI3 is an 18-item self-report measure assessing the tendency to fear symptoms of anxiety based on the belief that they may have harmful consequences. Items are rated on a 5-point Likert scale ranging from 0 (very little) to 4 (very much). Factor analyses supports a robust 3-factor structure corresponding to the three theorized dimensions of anxiety sensitivity (fear of somatic sensations, “somatic”; fear of cognitive dyscontrol, “cognitive”, and fear of socially observable symptoms of anxiety, “social”; Taylor, Koch, Woody, & McLean, 1996; Zinbarg, Barlow, & Brown, 1997) wherein each factor consists of six items. The ASI-3 has demonstrated improved internal consistency and factorial validity relative to the original ASI (Peterson & Reiss, 1992). The ASI-3 has also demonstrated evidence for convergent, discriminant, and criterion validity (Taylor et al., 2007). Measures of AS demonstrate unique incremental validity beyond trait anxiety (Rapee & Medoro, 1994) and trait-level negative affectivity/neuroticism (Zvolensky, Kotov, Antipova, Leen-Feldner, & Schmidt, 2005). For the current sample, the internal consistency was acceptable for the total score (˛ = .92), the somatic subscale score (˛ = .86), the cognitive subscale score (˛ = .89), and the social subscale score (˛ = .82). The average interitem correlation was .38. Brief Fear of Negative Evaluation scale, version 2 (BFNE-II; Carleton et al., 2007; Carleton, McCreary, Norton, & Asmundson, 2006). The BFNE-II is a 12-item revised version of the Brief Fear of Negative Evaluation scale (BFNE; Leary, 1983) used for measuring fears of negative evaluation. The BFNE has been correlated with the Social Avoidance and Distress Scale (SADS; Watson & Friend, 1969); however, it more accurately depicts fear of negative evaluation than it does social anxiety (Miller, 1995). Revisions to the BFNE were made in accordance with previously suggested changes (Taylor, 1993) to remove a methodological issue stemming from four reverseworded items by revising those items to be straightforwardly worded (Carleton et al., 2007, 2006; Weeks et al., 2005). Items are rated on a 5-point Likert scale ranging from 0 (not at all characteristic of me) to 4 (extremely characteristic of me). The BFNE-II has been

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shown to have excellent internal consistency, to correlate highly with the original scale, and factor analyses have supported a unitary solution (Carleton et al., 2007, 2006). For the current sample, the internal consistency was acceptable (˛ = .97) and the average inter-item correlation was .73. Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). The CES-D is a 20-item measure that assesses symptoms of depression. Respondents rate how frequently each item applied to them over the course of the past week using a 4-point Likert scale ranging from 0 (Rarely or none of the time [less than 1 day]) to 3 (Most or all of the time [5–7 days]). Substantial evidence supports the CES-D as a measure of depression symptoms (Boyd, Weissman, Thompson, & Myers, 1982; Roberts, Lewinsohn, & Seeley, 1991; Santor, Zuroff, Ramsay, Cervantes, & Palacios, 1995; Weissman, Sholomskas, Pottenger, Prusoff, & Locke, 1977). For the current sample, the internal consistency was acceptable (˛ = .93) and the average inter-item correlation was .38. 2.3. Analyses The first analyses were designed to further assess the endorsement rates of negative social events and create three groups. The number and type of distressing events, as well as the percentage of each distressing event selected as the worst event for each group are presented in Table 1. Participants were divided into one of three groups based on the types of events they reported as being the most distressing. The first group included persons who have experienced a significantly negative social event and believe it was the worst event they have ever experienced – the “Social Worst Event”. The Social Worst Event group included the only 13 people who did not report experiencing any Criterion A1 events and only reported experiencing a negative social event. The second group include persons who have experienced a significantly negative social event but believe some Criterion A1 event was the worst event they have ever experienced – the “Other Worst Event”. The third group included persons who have never experienced a significantly negative social event, but have experienced some Criterion A1 event and believe one such event was the worst they have ever experienced – the “No Social Event” group. Thereafter, descriptive statistics were calculated for the subscales and total scores of each of the self-report measures. For descriptive purposes, participants were also grouped into four proxy diagnostic categories based on their reported symptoms beyond the clinically significant cut-off scores on the SIPS, PCL-C, or both (i.e., PTSD/SAD, PTSD, SAD, neither; Table 1). A chisquare analysis was performed to compare the ratios of the four categories within each of the three experiential groups. The next analyses were designed to compare social anxiety and PTSS symptom reporting across the three groups. Analysis of variance (ANOVA) was used to evaluate whether participant responses on the dependent variables differed across each of the three experiential groups. Between-group differences were then delineated with Tukey post hoc tests. The final analyses were designed to evaluate the interrelationships between PTSS and SAD symptoms, and the common Table 1 Participant classification.

PTSD and SAD PTSD only SAD only Neither PTSD nor SAD Total

Social Worst Event (n)

Other Worst Event (n)

No Social Event (n)

9% (10) 6% (7) 14% (16) 71% (79) 100% (112)

11% (23) 12% (25) 7% (15) 71% (151) 100% (214)

1% (4) 7% (20) 9% (25) 82% (226) 100% (275)

Notes: PTSD – posttraumatic stress disorder (in the Social Worst Event group a negative social event was allowed to meet Criterion A); SAD – social anxiety disorder.

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Table 2 Percentages of participants reporting lifetime (worst) experiences of each trauma type.

Natural disaster (e.g., tornado, flood) Motor vehicle accident Other serious accident (e.g., industrial, farm) Fire Seeing someone being seriously injured or killed Sexual assault Physical assault Military combat or peacekeeping in a war zone Civilian (i.e., non-military) living in a war zone Terrorist attack Torture Unexpected death of loved one Armed robbery Serious illness (e.g., cancer, AIDS) Other Social

Social Worst Event (n = 112)

Other Worst Event (n = 214)

No Social Event (n = 275)

19% (0%) 59% (0%) 7% (0%) 22% (0%) 21% (0%) 14% (0%) 45% (0%) 0% (0%) 1% (0%) 3% (0%) 4% (0%) 31% (0%) 2% (0%) 42% (0%) 2% (0%) 100% (100%)

31% (1%) 82% (18%) 18% (2%) 40% (2%) 50% (7%) 38% (22%) 64% (6%) 1% (0%) 2% (0%) 3% (0%) 9% (1%) 68% (25%) 8% (0%) 57% (12%) 25% (4%) 100% (0%)

17% (2%) 72% (22%) 10% (1%) 20% (1%) 25% (8%) 18% (11%) 37% (7%) 1% (0%) 1% (0%) 2% (0%) 1% (0%) 48% (31%) 3% (1%) 41% (13%) 19% (3%) 0% (0%)

constructs (i.e., fear of negative evaluation, anxiety sensitivity, and depression). Accordingly, Pearson correlations and regressions were performed to evaluate the contributions of the independent variables (i.e., BFNE-II, ASI-3, CES-D, and SIPS or PCL-C scores, respectively) to either PCL-C total scores or SIPS total scores. The regression series placed the CES-D on the first step as per precedent research investigating social anxiety and PTSD (Frueh et al., 1996), as well as conducted in related research (McCabe et al., 2010). Although the current data will not allow for evaluations of causation, the regressions allow for inferences regarding the interactions of individual vulnerabilities on symptom presentations within each of the Social Worst Event, Other Worst Event, and No Social Event groups.

3. Results 3.1. Descriptive statistics Based on participant responses (Table 1), roughly a fifth of participants were classified as Social Worst Event (19%; n = 112), with approximately a third classified as Other Worst Event (35%; n = 214), and almost half as No Social Event (46%; n = 275). All but 13 participants reported experiencing multiple distressing events, with substantial overlap in reported events within and across the three experience groups (Table 2). As noted above, all 13 of the participants reporting only one distressing event were in the Social Worst Event group. There was also substantial comparability in length of time since the event occurred across groups (Table 3). The proportions of participants within each group reporting symptoms consistent with people meeting diagnostic criteria were also presented in Table 1. The chi-square analysis revealed no significant differences in the between-group ratios, 2 (6) = 6.45, p > .05, V = .04. Such results suggest against the notion that any one group was more likely to endorse symptoms of clinically significant distress. The resulting endorsement rates may at first seem high (Seedat &

Stein, 2001); however, it is important to note that these participants were self-selected for a study on fear and anxiety as well as being self-selected because they endorsed experiencing a significantly negative social event. Accordingly, the sample was not necessarily representative of the population, but representative of a subset particularly interested in fear and anxiety. Although not statistically analysed, the results in Tables 2 and 3 provide important data that serve to characterize the sample.

4. ANOVA comparisons between experiential groups The substantially different sample sizes within each of the symptoms groups, while not prohibitive for ANOVA, does make meeting the assumption of homogeneity of variance more important (Tabachnick & Fidell, 2001); however, even if violated, a Welch correction can be employed along with discriminating post hoc tests to ensure any statistically significant differences are likely to be robust (Judd, McClelland, & Culhane, 1995; Tabachnick & Fidell, 2001). The assumption of homogeneity was violated (p < .05) for all variables except the ASI-somatic subscale, the ASI-social subscale, and the BFNE-II total score. Accordingly, a Welch correction was applied to all F-values. The subsequent comparisons of response means between each of the experiential groups (i.e., Social Worst Event, Other Worst Event, No Social Event) revealed statistically significant differences (p < .05) for all but one variable (Table 4). Additional adjustments to control for Experiment-Wise Type I error were not included to avoid the risk of a Type II error (Tabachnick & Fidell, 2001); accordingly, a primary focus of the comparisons should be on the effect sizes (Osborne, 2008). The Social Worst Event and Other Worst Event groups reported higher levels of PTSS and SAD symptoms, as well as higher levels of anxiety sensitivity and fear of negative evaluation, particularly if the negative social event was considered their most distressing event. The differences may reflect an increased vulnerability associated with experiencing social events as distressing.

Table 3 Event occurrence timelines. Within the last month (n) Happened only once Never Social 4% (6) Social, Not Worst 0% (0) Worst was Social 9% (2) Happened more than once, but most recently Never Social 1% (1) Social, Not Worst 3% (3) Worst was Social 0% (0)

1–3 months ago (n)

4–6 months ago (n)

7–12 months ago (n)

1–3 years ago (n)

4+ years ago (n)

4% (6) 3% (3) 0% (0)

3% (5) 5% (5) 5% (1)

10% (16) 5% (5) 5% (1)

30% (47) 37% (35) 24% (5)

49% (75) 50% (47) 57% (12)

3% (4) 3% (4) 1% (1)

3% (4) 1% (1) 1% (1)

8% (10) 6% (7) 1% (1)

28% (33) 24% (29) 8% (7)

57% (68) 63% (75) 89% (81)

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Table 4 ANOVA comparison results. Social Worst Event (n = 112) PCL-C reexperiencing PCL-C Avoidance PCL-C Numbing PCL-C Hyperarousal PCL-C Total ASI-3 Somatic ASI-3 Cognitive ASI-3 Social ASI-3 Total BFNE-II Total SIPS Total CES-D Total

a

Other Worst Event (n = 214)

No Social Event (n = 275)

b

9.31 (4.86) 4.22b (2.30) 9.63b (5.30) 10.22b (5.56) 33.39b (16.11) 5.08b (5.38) 4.54b (5.29) 9.26b (5.97) 18.88b (14.21) 26.18b (14.08) 18.69b (14.22) 19.57b (13.09)

Welch F

a

10.93 (5.40) 4.72b (2.59) 9.73b (5.20) 11.03b (5.99) 36.40b (17.01) 5.61b (5.29) 4.87b (5.21) 8.75ab (5.67) 19.23b (13.79) 23.83ab (14.37) 16.58ab (14.23) 21.67b (13.39)

***

8.53 (4.42) 3.47a (2.05) 7.65a (4.07) 8.07a (4.51) 27.71a (13.32) 4.29a (4.72) 3.25a (4.42) 7.74a (5.25) 15.28a (11.89) 20.96b (13.68) 14.20a (11.69) 16.00a (10.88)

13.84 17.91*** 14.53*** 20.39*** 20.36*** 4.19* 7.44*** 3.69* 6.61** 6.22** 5.12** 13.40***

eta2 .047 .058 .045 .063 .063 .014 .024 .012 .021 .020 .017 .043

Notes: Means with difference superscripts are significantly different using Tukey post hoc tests; PCL-C – Posttraumatic Check List – Civilian version; SIPS – Social Interaction Phobia Scale; ASI-3 – Anxiety Sensitivity Index-3; BFNE-II – Brief Fear of Negative Evaluation scale, version 2; CES-D – Center for Epidemiologic Studies Depression Scale. * p < .05. ** p < .01. *** p < .001. Table 5 Pearson correlations. 1 1. ASI-3 somatic 2. ASI-3 Cognitive 3. ASI-3 social 4. BFNE-II total 5. CES-D total 6. PCL-C reexperiencing 7. PCL-C 8. avoidance 9. PCL-C numbing 10. PCL-C hyperarousal

2

.62 – .58 .46 .56 .36 .27 .46 .46

3

4

5

.68 .48 .32 .31

.42 .46 .68 – .49 .24 .24

.43 .56 .48 .49 – .49 .41

.33 .36 .32 .24 .49 – .73

.40 .37

.32 .30

.59 .61

.71 .72

.52 .58 –

6

7 .27 .27 .31 .24 .41 .73

– .67 .60

8 .42 .46 .40 .32 .59 .71 .67

– .81

9 .42 .46 .37 .30 .61 .72 .60

.45 .54 .68 .66 .54 .33 .34

.81 –

.42 .42

Notes: All correlations were significant (p < .01); PCL-C – Posttraumatic Check List – Civilian version; SIPS – Social Interaction Phobia Scale; ASI-3 – Anxiety Sensitivity Index-3; BFNE-II – Brief Fear of Negative Evaluation scale, version 2; CES-D – Center for Epidemiologic Studies Depression Scale.

4.1. Correlation and regression analyses The inter-subscale correlations are presented in Table 5. All of the relationships were statistically significant. The regressions used the CES-D, BFNE-II, ASI-3 social subscale, and SIPS scores as predictors of current PCL-C scores for each of the Social Worst Event, Other Worst Event, and No Social Event groups.1 For participants in the Social Worst Event group, CES-D, BFNE-II, ASI-3 social subscale, and PCL-C scores (specific to the social event they identified as the most distressing event) were all statistically significant predictors of their current SIPS scores and accounted for a substantial portion of variance. In contrast, only their CES-D scores and SIPS scores were statistically significant predictors of their PCL-C scores, though accounting for relatively little variance. These results suggest that the significantly negative social event may be a key vulnerability factor for social anxiety, rather than social anxiety making people vulnerable to experience events as particularly negative (Table 6). For participants in the Other Worst Event group, CES-D, BFNE-II, the ASI-3 social subscale, the ASI-3 cognitive subscale, and PCL-C scores (related to the most distressing Criterion A1 event) were all statistically significant predictors of SIPS scores (Table 6). In contrast, the ASI-3 somatic subscale, the ASI-3 cognitive subscale, and SIPS scores were statistically significant predictors of PCL-C scores. The results suggest that a significantly negative social event and a

1 The regression coefficients for some of the statistically insignificant predictors reverse, suggesting the possibility of suppression or multicollinearity; however, when the regressions were systematically re-ran without each variable that reversed, the variance accounted for in the dependent variable changed by less than 1%, suggesting the impact of those variables was not artificially inflating the variance accounted for.

Criterion A1 event may serve as vulnerability factors for symptoms of SAD and PTSD, or that the vulnerability factors may serve to make participants more likely to perceive several events as distressing. For participants in the No Social Event group, CES-D, BFNEII, the ASI-3 social subscale, and the ASI-cognitive subscale were all statistically significant predictors of SIPS scores (Table 6). In contrast, only the ASI-3 somatic subscale and the ASI-3 cognitive subscale were statistically significant predictors of PCL-C scores. These results suggest against a robust relationship between PTSS and SAD symptoms, but a consistent relationship between fear of negative evaluation and the non-somatic components of anxiety sensitivity. In contrast to the Social Worst Event group results – there was no significant relationship between PCL-C scores and SIPS scores, suggesting that the type of trauma experienced (i.e., social traumatic event versus a Criterion A1 event) may impact the nature of subsequent symptom development. The results of this regression, along with those from the Social Worst Event group, serve to further underscore that a distressing social event is likely a significant vulnerability factor for the development of social anxiety symptoms and SAD.

5. Discussion The present investigation was conducted for three reasons. First, to further assess the endorsement rates of significantly negative social events perceived as distressing or traumatic. Second, to compare PTSS and SAD symptom reporting, depending on whether the participants believed the most distressing event they experienced was a significantly negative social event, a Criterion A1 event despite believing they had experienced a significantly negative social event, or only a Criterion A1 event. Third, to evaluate

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Table 6 Subsequent regression results. Dependent variable: PCL-C

Dependent variable: SIPS

Coefficient statistics

Social Worst Event CES-D (Constant) BFNE-II ASI-Somatic ASI-Cognitive ASI-Social SIPS Total Other Worst Event CES-D (Constant) BFNE-II ASI-Somatic ASI-Cognitive ASI-Social SIPS Total No Social Event CES-D (Constant) BFNE-II ASI-Somatic ASI-Cognitive ASI-Social SIPS Total

Model statistics

Coefficient statistics

ˇ

t

part r

R2

F

ˇ

t

.62

7.06** 5.62** −.14 1.10 −.83 .50 2.01**

.44

.55 .05

132.07** 2.32*

.13

1.24 −1.88 2.75** 1.01 −.40 3.55** 2.01**

−.01 .09 −.08 .05 .20 .41 −.24 .23 .04 .07 .25 .48 −.06 .11 .06 .10 −.10

−.01 .07 .05 .03 .13

5.97** 10.35** −2.99** 3.24** .58 .84 3.14**

.31

7.54** 11.88** −.83 1.69 .87 1.22 −1.26

.38

.32 .12

99.66** 21.56**

−.16 .17 .03 .04 .16 .28 .03

106.31** 1.96

−.04 .09 .04 .06 −.06

CES-D (Constant) BFNE-II ASI-Somatic ASI-Cognitive ASI-Social PCL-C Total CES-D (Constant) BFNE-II ASI-Somatic ASI-Cognitive ASI-Social PCL-C Total CES-D (Constant) BFNE-II ASI-Somatic ASI-Cognitive ASI-Social PCL-C Total

.23 .08 −.04 .35 .19 .08 .31 −.07 .18 .28 .18 .19 .36 .02 .11 .28 −.06

1.25 −3.31** 4.58** −1.07 2.73** 4.09** 3.14** 3.48** −.01 6.52** .42 1.95* 4.60** −1.26

Model statistics part r

R2

F

.33 .27

54.43** 14.57**

.30 .29

91.89** 29.43**

.25 .32

89.88** 39.84**

.08 .17 .06 −.02 .22 .06 .20 −.05 .12 .18 .14 .14 .26 .02 .08 .18 −.05

Notes: PCL-C – Posttraumatic Check List – Civilian version; SIPS – Social Interaction Phobia Scale; ASI-3 – Anxiety Sensitivity Index-3; BFNE-II – Brief Fear of Negative Evaluation scale, version 2; CES-D – Center for Epidemiologic Studies Depression Scale. * p < .05. ** p < .01.

the interrelationships between PTSS and SAD symptoms, and common constructs including fear of negative evaluation (Storch et al., 2003), anxiety sensitivity (Collimore et al., 2008; Ressler et al., 2004; Storch et al., 2003), and depression (Otto et al., 2009; Turner et al., 2005) within each of the three aforementioned groups. The current results suggest that a substantial proportion of people report experiencing a distressing social event. Moreover, approximately one in three people reporting a distressing social event reported it as being the most distressing event they have experienced, despite most also having experienced Criterion A1 events. Fewer than one in 10 endorsed a social event as being significantly distressing without also endorsing a Criterion A1 event. These endorsement rates converge with precedent findings (Abramowitz et al., 2009; Ward, 2006), further suggesting that negative social events can have severe and lasting effects on individual well-being. In comparing the PTSS and SAD symptoms across the three groups (i.e., Social Worst Event, Other Worst Event, No Social Event), a general pattern emerged. Participants reporting a significantly negative social event, whether it was the worse event or not, also reported higher levels of PTSS and SAD symptoms, as well as higher levels of fear of negative evaluation and anxiety sensitivity. Those who reported that the significantly negative social event was the worst event they had experienced also endorsed the highest levels of social anxiety and fear of negative evaluation; however, the levels were not statistically significantly higher than those who endorsed a significantly negative social event in addition to a Criterion A1 event. In line with precedent research (Ward, 2006), these findings suggest that a significantly negative social event may function as a key precipitating event for SAD; however, SAD may also develop in the absence of such an event, but perhaps less often than currently thought. Some individuals appear to be more vulnerable to perceive events as being distressing – irrespective of whether or not the event meets the threshold of a Criterion A1 event – and, consequently, these individuals may be more at risk for the development of psychopathology (Rapee & Spence, 2004).

The implication is that the same individual differences may make a person vulnerable to interpret an event as distressing as to develop PTSS and social anxiety symptoms. For persons with a history of a significantly negative social event, the results of the regression analyses suggest that it may have been a diathesis, even after controlling for the influence of depression. Depression, fear of negative evaluation, anxiety sensitivity, and PTSS were significant predictors of substantial variance in social anxiety, suggesting those independent variables may have preceded the dependent social anxiety variable (Petrocelli, 2003); however, when the equation was reversed, only depression and social anxiety symptoms predicted PTSS, and the variance accounted for was much smaller. In other words, fears of negative evaluation and socially observable symptoms of anxiety do not appear to have made them more likely to consider a negative social event traumatic; instead, the negative social event – either alone or in combination with individual differences such as high fear of negative evaluation and high fear of socially observable symptoms – appears to have made them more socially anxious. The aversive social event may have been a precipitating factor in the onset of social anxiety symptoms. This notion of an event having etiological significance has been supported, in part, by research suggesting that some individuals report a conditioning event that instigates social anxiety symptoms (McCabe et al., 2010; McNally, 2009; Ward, 2006) as well as other anxiety symptoms (McNally, 2007; V.J. McNally, 2006). Although this speculation is consistent with the statistical information and appears in line with existing diatheses-stress (Rapee & Spence, 2004) and maintenance (Rapee & Heimberg, 1997) models for SAD, the current data are crosssectional. Nevertheless, research to date suggests that longitudinal and cross-sectional studies generally provide similar evidence in this area (Craig, 1998; Hawker & Boulton, 2000; Storch & Ledley, 2005; Storch et al., 2004). An important exception occurred within one of the two aforementioned precedent investigations, wherein a direct causal relationship between a negative social event and

R.N. Carleton et al. / Journal of Anxiety Disorders 25 (2011) 49–57

a specific phobia of speeches was not found, suggesting a relatively complex etiological pattern for symptoms associated with SAD (Hofmann et al., 1995). In cases where individuals reported experiencing both kinds of distressing events (i.e., a significantly negative social event and a Criterion A1 event), the PTSS and social anxiety symptoms were highly correlated, as might be expected given the reporting of multiple distressing events. These individuals may have naturally had higher levels of anxiety, thereby making them particularly prone to interpret a variety of experiences as distressing or traumatic. Alternatively, they may have experienced a variety of distressing events and subsequently have become increasingly anxious. In the absence of longitudinal data, causality remains speculative. These results suggest a more diffuse interaction between PTSS and social anxiety symptoms, as might be expected given the reporting of multiple distressing events; moreover, the results are in line with precedent research showing inconsistent relationships between PTSS and SAD (Abramowitz et al., 2009; Asmundson & Carleton, 2005; Davidson et al., 1993). For individuals reporting Criterion A1 trauma(s) but no significantly negative social event, social anxiety symptoms were associated with variables commonly associated with SAD (i.e., depression, fear of negative evaluation, fear of socially observable symptoms of anxiety, and fear of cognitive dyscontrol; e.g., McNally, 2006a, 2006b). Similarly, their PTSS were associated with variables commonly associated with PTSD (i.e., fear of somatic sensations related to anxiety and fear of cognitive dyscontrol). Moreover, the results further support precedent research of a relatively inconsistent relationship between fear of negative evaluation and PTSD (Asmundson & Carleton, 2005; Storch et al., 2003), while evidence continues to grow for a consistent relationship between anxiety sensitivity and PTSS (Asmundson, Norton, Allerdings, Norton, & Larsen, 1998; Taylor, Koch, & McNally, 1992). In other words, the distressing experience was not particularly associated with social anxiety symptoms, and social anxiety symptoms were not particularly associated with other distressing events. The current results are in line with research that has shown the relationship between fear of negative evaluation and PTSS to be inconsistent (Hofmann, Litz, & Weathers, 2003; Storch et al., 2003). These results also add to growing evidence of a consistent relationship between anxiety sensitivity and PTSS (Orsillo et al., 1996); moreover, the results are directly in line with the current models for SAD (Rapee & Heimberg, 1997; Rapee & Spence, 2004). That is, the relationship between PTSD and social anxiety symptoms may be mitigated by the experience of a distressing social event. The relationship between social anxiety symptoms, fear of negative evaluation, and socially observable symptoms of anxiety also appeared to be robustly interdependent, as per previous research in the area (Hinton, Chhean, Fama, Pollack, & McNally, 2007). This study has some limitations that provide directions for future research. First, the clinical significance of social anxiety and PTSS were measured by self-report measures rather than clinical interviews. As such, the proxy diagnostic categories were dependent on such measures; however, this limitation should be attenuated by the quality of the measures used in this study. Future research should consider using clinical interviews to augment selfreport measures. In the interim, it is important to recognize that the current results focus on symptoms, rather than diagnoses. As such, any extrapolations to diagnostic clinical samples should focus primarily on patterns of symptom presentation, not differential diagnoses. A second, related limitation is that the age of each distressing event, as well as the frequency of each event – beyond once or more than once – was not recorded. Future research should ensure that these data are collected to better evaluate the temporal effects of the events. Similarly, significant symptoms of social anxiety in the absence of a history of negative social events is

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counterintuitive and not necessarily in line with precedent theory (Hofmann et al., 1995; Rapee & Heimberg, 1997; Rapee & Spence, 2004). Future research should examine negative social events in greater depth to further contextualize the experience. Previous research in this area has already demonstrated success with retrospective data (McCabe et al., 2010), supporting such a data collection effort. Third, it is very likely that adults with disorders other than SAD may have high social anxiety. Specifically, adults with Asperger’s Disorder (Kuusikko et al., 2008) and even Attention Deficit/Hyper Activity Disorder (Van Ameringen, Mancini, Simpson, & Patterson, 2010) may report high social anxiety as a result of a negative social event. Accordingly, future research should explore the impact of such events on individuals with social anxiety secondary to other disorders. Fourth, the comparisons and the regressions both depended on cross-sectional data. Despite previous evidence suggesting cross-sectional and longitudinal data can produce similar results (Craig, 1998; Hawker & Boulton, 2000; Storch & Ledley, 2005; Storch et al., 2004), longitudinal studies appear increasingly warranted to further explore the etiological nature of SAD. Fifth, additional information regarding distressing or traumatic events would have been useful, such as assessing the circumstances surrounding the event (e.g., age of onset, perceived severity). Sixth, although anxiety sensitivity was examined, other potentially important vulnerability factors, such as family history of depression, trait anxiety, and personality indicators such as neuroticism were not assessed. As a result, it is difficult to discern what additional factors may have contributed to the presence of self-reported PTSS and SAD symptoms. Subsequent cross-sectional research may circumvent some of these shortcomings by obtaining a more detailed history of psychopathology. Seventh, the notion of what constitutes a distressing social event remains to be explored. For example, many distressing events involve a social component (e.g., divorce), without necessarily having fear of negative evaluation as the primary concern (e.g., the end of the relationship is more likely to be primary for divorce). Nonetheless, future research should explore the impact of such events on SAD symptoms. Despite the aforementioned limitations, the current results add to a growing body of research demonstrating pervasive and distressing effects associated with negative social events. In the context of assessment, it may be important for clinicians to be particularly mindful that distressing negative social events can have a significant negative impact on mental health. Such events may be particularly salient for case conceptualization and treatment planning without necessarily being directly associated with Criterion A1 from PTSD (Beidel, 1991; McNally, 2003). In terms of intervention, some clients may find processing distressing negative social events to be an effective means of symptom reduction – as an adjunct to empirically-supported treatments for SAD; however, this remains to be evaluated empirically. Overall, identifying and addressing overlapping symptoms irrespective of formal diagnostic category may prove more useful for persons suffering from SAD. Acknowledgements The authors would like to very gratefully acknowledge Drs. Meredith Coles and Richard Heimberg for their insightful comments supporting our statistical analyses and theory development. References Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. Lancet, 374(9688), 491–499. Albano, A. M., & Detweiler, M. F. (2001). The developmental and clinical impract of social anxiety and social phobia in children and adolescents. In: S. G. Hofmann, & P. M. DiBartolo (Eds.), From social anxiety to social phobia: multiple perspectives. Needham Heights, MA: Allyn & Bacon.

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R.N. Carleton et al. / Journal of Anxiety Disorders 25 (2011) 49–57

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision ed.). Washington, DC: Author. Andrykowski, M. A., Cordova, M. J., Studts, J. L., & Miller, T. W. (1998). Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist – Civilian Version (PCL – C) as a screening instrument. Journal of Consulting and Clinical Psychology, 66(3), 586–590. Asmundson, G. J. G., & Carleton, R. N. (2005). Fear of pain is elevated in adults with co-occurring trauma-related stress and social anxiety symptoms. Cognitive Behaviour Therapy, 34, 248–255. Asmundson, G. J. G., Norton, G. R., Allerdings, M. D., Norton, P. J., & Larsen, D. K. (1998). Posttraumatic stress disorder and work-related injury. Journal of Anxiety Disorders, 12(1), 57–69. Asmundson, G. J. G., Stapleton, J. A., & Taylor, S. (2004). Are avoidance and numbing distinct PTSD symptom clusters? Journal of Traumatic Stress, 17(6), 467–475. Barlow, D. H. (2002). Anxiety and Its Disorders (2nd ed.). New York, NY: Guilford Press. Beidel, D. C. (1991). Environmental events and psychopathology. Restoring the balance. Behavior Modification, 15(4), 451–455. Beidel, D. C. (1998). Social anxiety disorder: etiology and early clinical presentation. Journal of Clinical Psychiatry, 59(Suppl. 17), 27–32. Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34(8), 669–673. Boyd, J. H., Weissman, M. M., Thompson, W. D., & Myers, J. K. (1982). Screening for depression in a community sample. Understanding the discrepancies between depression symptom and diagnostic scales. Archives of General Psychiatry, 39(10), 1195–1200. Buckley, T. C., Blanchard, E. B., & Hickling, E. J. (1996). A prospective examination of delayed onset PTSD secondary to motor vehicle accidents. Journal of Abnormal Psychology, 105(4), 617–625. Carleton, R. N., & Asmundson, G. J. G. (2009). The multidimensionality of fear of pain: construct independence for the Fear of Pain Questionnaire-Short Form and the Pain Anxiety Symptoms Scale-20. The Journal of Pain, 10, 29–37. Carleton, R. N., Collimore, K. C., Asmundson, G. J., McCabe, R. E., Rowa, K., & Antony, M. M. (2009). Refining and validating the Social Interaction Anxiety Scale and the Social Phobia Scale. Depression and Anxiety, 26(2), E71–81. Carleton, R. N., Collimore, K. C., & Asmundson, G. J. G. (2007). Social anxiety and fear of negative evaluation: construct validity of the BFNE-II. Journal of Anxiety Disorders, 21(1), 131–141. Carleton, R. N., Gosselin, P., & Asmundson, G. J. G. (2010). The Intolerance of Uncertainty Index: replication and extension with an English sample. Psychological Assessment, 22, 396–406. Carleton, R. N., McCreary, D. R., Norton, P. J., & Asmundson, G. J. G. (2006). Brief fear of negative evaluation scale-revised. Depression and Anxiety, 23(5), 297–303. Chasson, G. S., Buhlmann, U., Tolin, D. F., Rao, S. R., Reese, H. E., Rowley, T., et al. (2010). Need for speed: Evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine. Behaviour Research and Therapy, 48, 675–679. Collimore, K. C., McCabe, R. E., Carleton, R. N., & Asmundson, G. J. G. (2008). Media exposure and dimensions of anxiety sensitivity: differential associations with PTSD symptom clusters. Journal of Anxiety Disorders, 22(6), 1021–1028. Cordova, M. J., Andrykowski, M. A., Kenady, D. E., McGrath, P. C., Sloan, D. A., & Redd, W. H. (1995). Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer. Journal of Consulting and Clinical Psychology, 63(6), 981–986. Craig, W. M. (1998). The relationship among bullying, victimization, depression, anxiety, and aggression in elementary school children. Personality and Individual Differences, 24, 123–130. Davidson, J. R., Kudler, H. S., Saunders, W. B., Erickson, L., Smith, R. D., Stein, R. M., et al. (1993). Predicting response to amitriptyline in posttraumatic stress disorder. American Journal of Psychiatry, 150(7), 1024–1029. Erwin, B. A., Heimberg, R. G., Marx, B. P., & Franklin, M. E. (2006). Traumatic and socially stressful life events among persons with social anxiety disorder. Journal of Anxiety Disorders, 20(7), 896–914. Forbes, D., Creamer, M., & Biddle, D. (2001). The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. Behaviour Research and Therapy, 39(8), 977–986. Frueh, B. C., Turner, S. M., Beidel, D. C., Mirabella, R. F., & Jones, W. J. (1996). Trauma management therapy: a preliminary evaluation of a multicomponent behavioral treatment for chronic combat-related PTSD. Behaviour Research and Therapy, 34(7), 533–543. Gatz, M., Johansson, B., Pedersen, N., Berg, S., & Reynolds, C. (1993). A cross-national self-report measure of depressive symptomatology. International Psychogeriatrics, 5(2), 147–156. Gosling, S. D., Vazire, S., Srivastava, S., & John, O. P. (2004). Should we trust webbased studies? A comparative analysis of six preconceptions about internet questionnaires. American Psychologist, 59(2), 93–104. Hawker, D. S., & Boulton, M. J. (2000). Twenty years’ research on peer victimization and psychosocial maladjustment: a meta-analytic review of cross-sectional studies. Journal of Child Psychology and Psychiatry, 41(4), 441–455. Henderson, L., & Zimbardo, P. (2001). Shyness, social anxiety, social phobia. In: S. G. Hofmann, & P. M. DiBartolo (Eds.), From social anxiety to social phobia: multiple perspectives. Needham Heights, MA: Allyn & Bacon. Hinton, D. E., Chhean, D., Fama, J. M., Pollack, M. H., & McNally, R. J. (2007). Gastrointestinal-focused panic attacks among Cambodian refugees: associated psychopathology, flashbacks, and catastrophic cognitions. Journal of Anxiety Disorders, 21(1), 42–58.

Hofmann, S. G., Ehlers, A., & Roth, W. T. (1995). Conditioning theory: a model for the etiology of public speaking anxiety? Behaviour Research and Therapy, 33(5), 567–571. Hofmann, S. G., Litz, B. T., & Weathers, F. W. (2003). Social anxiety, depression, and PTSD in Vietnam veterans. Journal of Anxiety Disorders, 17(5), 573–582. Judd, C. M., McClelland, G. H., & Culhane, S. E. (1995). Data analysis: continuing issues in the everyday analysis of psychological data. Annual Review of Psychology, 46, 433–465. Kuusikko, S., Pollock-Wurman, R., Jussila, K., Carter, A. S., Mattila, M. L., Ebeling, H., et al. (2008). Social anxiety in high-functioning children and adolescents with Autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 38(9), 1697–1709. Leary, M. R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social Psychology Bulletin, 9, 371–375. Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36(4), 455–470. McCabe, R. E., Miller, J. L., Laugesen, N., Antony, M. M., & Young, L. (2010). The relationship between anxiety disorders in adults and recalled childhood teasing. Journal of Anxiety Disorders, 24(2), 238–243. McNally, R. J. (2003). Remembering trauma. Cambridge: Harvard University Press. McNally, R. J. (2006a). Applying biological data in the forensic and policy arenas. Annals of the New York Academy of Sciences, 1071, 267–276. McNally, R. J. (2006b). Cognitive abnormalities in post-traumatic stress disorder. Trends in Cognitive Sciences, 10(6), 271–277. McNally, R. J. (2007). Can we solve the mysteries of the National Vietnam Veterans Readjustment Study? Journal of Anxiety Disorders, 21(2), 192–200. McNally, R. J. (2009). Can we fix PTSD in DSM-V? Depression and Anxiety, 26(7), 597–600. McNally, V. J. (2006). The impact of posttraumatic sress on Iraqi police. International Journal of Emergency Mental Health, 8(4), 275–281. Miller, M. B. (1995). Coefficient alpha: a basic introduction from the perspectives of classical test theory and structural equation modeling. Structural Equation Modeling, 2, 255–273. Morley, S., Williams, A. C., & Black, S. (2002). A confirmatory factor analysis of the Beck Depression Inventory in chronic pain. Pain, 99(1–2), 289–298. Orsillo, S. M., Weathers, F. W., Litz, B. T., Steinberg, H. R., Huska, J. A., & Keane, T. M. (1996). Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 184(5), 307–313. Osborne, J. W. (Ed.). (2008). Best practices in quantitative methods. Los Angeles: Sage Publications Inc. Otto, M. W., Tolin, D. F., Simon, N. M., Pearlson, G. D., Basden, S., Meunier, S. A., et al. (2009). Efficacy of d-cycloserine for enhancing response to cognitive-behavior therapy for panic disorder. Biological Psychiatry, 67(4), 365–370. Peterson, R. A., & Reiss, S. (1992). Anxiety sensitivity index manual (2nd ed.). Worthington, OH: International Diagnostic Systems. Petrocelli, J. V. (2003). Hierarchical multiple regression in counseling research: common problems and possible remedies. Measurement and Evaluation in Counseling and Development, 36(1), 9–22. Radloff, L. S. (1977). The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741–756. Rapee, R. M., & Medoro, L. (1994). Fear of physical sensations and trait anxiety as mediators of the response to hyperventilation in nonclinical subjects. Journal of Abnormal Psychology, 103(4), 693–699. Rapee, R. M., & Spence, S. H. (2004). The etiology of social phobia: empirical evidence and an initial model. Clinical Psychology Review, 24(7), 737–767. Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, K., Zimand, E., et al. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of dcycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry, 61, 1136–1144. Rigby, K. (2003). Consequences of bullying in schools. Canadian Journal of Psychiatry, 48(9), 583–590. Roberts, R. E., Lewinsohn, P. M., & Seeley, J. R. (1991). Screening for adolescent depression: a comparison of depression scales. Journal of the American Academy of Child and Adolescent Psychiatry, 30(1), 58–66. Roth, D. A., Coles, M. E., & Heimberg, R. G. (2002). The relationship between memories for childhood teasing and anxiety and depression in adulthood. Journal of Anxiety Disorders, 16(2), 149–164. Santor, D. A., Zuroff, D. C., Ramsay, J. O., Cervantes, P., & Palacios, J. (1995). Examining scale discriminability in the BDI and CES-D as a function of depressive severity. Psychological Assessment, 7(2), 131–139. Seedat, S., & Stein, D. J. (2001). Biological treatment of PTSD in children and adolescents. In: S. Eth (Ed.), PTSD in children and adolescents (pp. 87–116). Washington, DC: American Psychiatric Association. Stein, M. B., McQuaid, J. R., Pedrelli, P., Lenox, R., & McCahill, M. E. (2000). Posttraumatic stress disorder in the primary care medical setting. General Hospital Psychiatry, 22(4), 261–269. Storch, E. A., Brassard, M. R., & Masia-Warner, C. L. (2003). The relationship of peer victimization to social anxiety and loneliness in adolescence. Child Study Journal, 33, 1–19. Storch, E. A., & Ledley, D. R. (2005). Peer victimization and psychosocial adjustment in children: current knowledge and future directions. Clinical Pediatrics (Philadelphia), 44(1), 29–38.

R.N. Carleton et al. / Journal of Anxiety Disorders 25 (2011) 49–57 Storch, E. A., Roth, D. A., Coles, M. E., Heimberg, R. G., Bravata, E. A., & Moser, J. (2004). The measurement and impact of childhood teasing in a sample of young adults. Journal of Anxiety Disorders, 18(5), 681–694. Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). New York, NY: Harper and Row. Taylor, S. (1993). The structure of fundamental fears. Journal of Behavior Therapy and Experimental Psychiatry, 24(4), 289–299. Taylor, S., Koch, W. J., & McNally, R. J. (1992). How does anxiety sensitivity vary across the anxiety disorders? Journal of Anxiety Disorders, 6, 249–259. Taylor, S., Koch, W. J., Woody, S., & McLean, P. (1996). Anxiety sensitivity and depression: how are they related? Journal of Abnormal Psychology, 105(3), 474–479. Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., et al. (2007). Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19(2), 176–188. Turner, S. M., Beidel, D. C., & Frueh, B. C. (2005). Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: trauma management therapy. Behavior Modification, 29(1), 39–69. Van Ameringen, M., Mancini, C., Simpson, W., & Patterson, B. (2010). Adult attention deficit hyperactivity disorder in an anxiety disorders population. CNS Neuroscience & Therapeutics. Vanheule, S., Desmet, M., Groenvynck, H., Rosseel, Y., & Fontaine, J. (2008). The factor structure of the Beck Depression Inventory-II: an evaluation. Assessment, 15(2), 177–187.

57

Ward, L. C. (2006). Comparison of factor structure models for the Beck Depression Inventory – II. Psychological Assessment, 18(1), 81–88. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33(4), 448–457. Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The PTSD Checklist: reliability, validity, & diagnostic utility. Paper presented at the Meeting of the International Society for Traumatic Stress Studies. Weathers, F. W., Litz, B. T., Huska, J. A., & Keane, T. M. (1994). PTSD checklist civilian version. Boston National Center for PTSD, Behavioral Science Division. Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. A., Turk, C. L., Schneier, F. R., et al. (2005). Empirical validation and psychometric evaluation of the brief fear of negative evaluation scale in patients with social anxiety disorder. Psychological Assessment, 17(2), 179–190. Weissman, M. M., Sholomskas, D., Pottenger, M., Prusoff, B. A., & Locke, B. Z. (1977). Assessing depressive symptoms in five psychiatric populations: a validation study. American Journal of Epidemiology, 106(3), 203–214. Zinbarg, R. E., Barlow, D. H., & Brown, T. A. (1997). Hierarchical structure and general factor saturation of the anxiety sensitivity index. Psychological Assessment, 9, 277–284. Zvolensky, M. J., Kotov, R., Antipova, A. V., Leen-Feldner, E. W., & Schmidt, N. B. (2005). Evaluating anxiety sensitivity, exposure to aversive life conditions, and problematic drinking in Russia: a test using an epidemiological sample. Addictive Behaviors, 30(3), 567–570.